Practice Member Health Questionnaire

Transcription

1 89 Route 101A Amherst, NH Practice Member Health Questionnaire Name What do you prefer to be called? Home Phone Cell Phone Work Phone Address City, State, Zip of Birth Would you like text message appointment reminders? Yes No If yes, who is your wireless carrier? Male/Female Age SS# Occupation Employer Employer's Phone# Employer's Address Marital Status: M W D S Spouse Name No# of Children Name of Children Do you have insurance? Yes No With what provider? Are you primary on that insurance? Yes No If not, please provide the name and DOB of subscriber and relationship: 1. Many patients are referred to our office by a family member or friend. How did you hear about us? 2. Research says your spine should be cared for regularly. How often do you get adjusted by a chiropractor? Frequently / Monthly / Only when I hurt / I have never been to a chiropractor 3. When was your last complete spinal examination including x-rays? Never 4. Do you know if you have an abnormal spinal curvature, spinal arthritis, or inherited spinal problems? Yes No 5. Over time spinal misalignments will cause arthritis and degeneration which results in grinding or cracking to be heard when you move your neck or back. Do you hear these sounds when you move your head or neck? Yes No 6. If your spine is out of alignment for a long time it can make you feel like you need to twist, stretch, or crack your neck or back. Do you often feel the need to crack or pop your neck or lower back? Yes No

2 89 Route 101A Amherst, NH Poor posture leads to poor health and early death. How would you rate your posture? Poor Excellent 8. Stress will cause you to accelerate spinal damage. Rate your stress level over the last 3 months. Calm/Relaxed Very tense/tight 9. Please circle or list any health symptoms or health complaints you are experiencing. Neck pain L/R Arm pain/numbness L/R Asthma Thyroid Back Pain L/R Leg pain L/R Cancer Allergies: Mid-back pain L/R Headaches/Migraines Constipation Lower-back pain L/R Diabetes I/II Menstrual pain 10. Prescription medications cause various side effects hide the severity of health problems and hinder the body's ability to heal. What medications are you currently taking? Please list any surgeries you have had: 12. Daily trauma, auto accident(s), and work injuries can cause serious spinal problems. When was your most recent injury at home? Car accident? Slip or fall? 13. Spinal health is vitally important to ensure a healthy pregnancy. Is there a chance you are pregnant? Yes No 14. Do you smoke? Yes No 15. Improper sleeping positions can cause spinal damage; what position do you sleep in: Back Stomach L Side R Side 16. Exercise level: Never X/week 17. Please list vitamins/supplements you take: The above information is true and accurate to the best of my knowledge. Patient Signature (Parent/Guardian): :

3 THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In the course of your care as a patient at Amherst Family Chiropractic Wellness Center, LLC we may use or disclose personal and health related information about you in the following ways: *Your personal health information, including of your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment. *Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, an HMO, a PPO, or your employer, if they are or may responsible for the payment of your services. *Your name, address, phone number, and your health care records may be used to contact you regarding appointment reminders, information about alternatives to your present care, inform you of health related meetings, workshops or products or and other information that may be of interest to you. If you are not at home to receive an appointment reminder, a message may be left on your answering machine. Further, you have the right to inspect or obtain a copy of the information we will use for these purposes. You also have the right to refuse to provide authorization for this office to contact you regarding these matters. If you do not provide us with this authorization it will not affect the care provide to you or the reimbursement avenues associated with your care. Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances: *If we are providing health care services to you based on the orders of another health care provider. *If we provide health care services to you in an emergency. *If we are required by law to provide care to you and we are unable to obtain your consent after attempting to do so. *If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care. *If we are ordered by the courts or another appropriate agency. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a different form please advise us in writing as to your preferences. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein. We are also required to provide you with this notice of our privacy practices with respect to your health information. We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all of your health information in our files. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you

4 should direct your complaint to: Edward J. Rusher, DC. If you would like further information about our privacy policies and practices please contact: Edward J. Rusher, DC. This office utilizes an open-adjusting environment for ongoing patient care. Open adjusting involves several patients being seen in the same adjusting room at the same time. Patients are within sight of one another and some ongoing routine details of care are discussed within earshot of other patients and staff. This environment is used for ongoing care and this is NOT the environment used for taking patient histories, providing examinations or presenting reports of findings. These procedures are completed in a private, confidential setting. The use of this format is intended to make your experience with our office more efficient and productive as well as to enhance your access to quality health care and health information. If you choose not to be adjusted in an open-adjusting environment other arrangements will be made for you. It is our desire for our staff to use your name, signature, photograph and/or radiograph on our Patient of the Week and Month, Referral Boards, X-Ray view boxes, family picture wall, Newsletter and In-Office promotions. It is our desire for our staff to use your name and/or signature on our sign-in sheets in order to verify your office or workshop visit. The use of this information is intended to make your experience with our office more efficient, productive and to further enhance your access to quality Chiropractic care. This notice is effective as of April 1, This notice, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created. My signature acknowledges that I have received a copy of this notice. Name (Please Print) Signature If you are a minor, or if you are being represented by another party Personal Representative (Print) Personal Representative Signature Description of the authority to act on behalf of the patient.

5 Informed Consent for Chiropractic Care When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both of us to be working for the same objective. It is important that each patient understand both the objective(s) and the method(s) that will be used to attain this objective. This will prevent any confusion or disappointment. You have the right, as a patient, to be informed about the condition and the recommended care to be provided so that you make the decision whether or not to undergo chiropractic care after being advised of the known benefits, risks, and alternatives. Chiropractic is a science, philosophy and art which concerns itself with the relationship between the spinal structure and the health of the nervous system. As chiropractors we understand that health is a state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity. One disturbance to the nervous system is called a vertebral subluxation. This occurs when one or more of the 24 vertebra in the spinal column become misaligned and/or do not move properly. This causes an unhealthy change to nerve function and interference to the nervous system. This may result in pain and dysfunction or may be entirely asymptomatic. Subluxations are corrected and/or reduced by a chiropractic adjustment. An adjustment is the specific application of force to correct and/or reduce vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. Adjustments are done by hand where the doctor will put pressure on the specific segment(s) of the spine to adjust the vertebrae into a better position. If at the beginning or during the course of care we encounter a non-chiropractic or unusual findings, we will advise you of those findings and recommend some further testing or refer you out to another health care provider. Chiropractic care has been proven to be very safe and effective. It is not unusual however, to be sore after your first few corrective adjustments. Although rare it is possible to suffer from other side effects; i.e. muscle spasms, stiffness, rib fracture, headache, dizziness and stroke. All questions regarding the doctor's objective to my care in this office has been answered to my complete satisfaction. The benefits, risks and alternatives of chiropractic care have been explained to me to my satisfaction. I have read and fully understand the above statements and therefore accept chiropractic care on this basis. Print Name Signature Consent to evaluate and adjust a minor child I, being the parent or legal guardian of have read and fully understand the above Informed Consent and hereby grant permission for my child to receive chiropractic care. Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-rays can be hazardous to an unborn child. of last menstrual cycle: Signature 89 Route 101A, Amherst, NH 03031

6 89 Route 101A Amherst, NH Patient Name: File: Standard Waiver of Liability: I understand I am financially responsible for any charges incurred at this office, for those patients using insurance, this would include co-pays, deductibles, and charges denied or not covered by my insurance company. I realize my care may be subject to pre-authorization by my insurance company, and I accept any responsibility for charges which may not be approved. My insurance company will review any/all documentation submitted by Amherst Family Chiropractic for review for medical necessity, however, final determination is based upon my insurance company's medical guidelines. Insurance policy limitations are per individual insurance policy plans, as are copayments, co-insurance, deductibles, referrals, etc. I understand this office agrees to notify me as soon as possible whether my care is approved or denied by my insurance company. I further understand my initial visits may be denied and this may be beyond the office's ability to notify me prior to rendering acute care, while waiting for insurance coverage approval. These charges will be my responsibility if denied by my insurance company. Note: Our office does not bill secondary insurance carriers. I understand this office will require payment from me for any services not covered by my health insurance plan. Any payment due beyond 30 days is subject to late fees, interest at 1.5% per month and collection agency fees. I agree to pay all collection costs associated with collecting said debt, including, but not limited to attorney fees of 25% (twentyfive percent), together with the costs and disbursements of the action. Assignment of Benefits: I hereby authorize my insurance benefits to be paid directly to Dr. Edward Rusher. I have read this document and understand my obligations for payment for care in the absence of insurance coverage. Signature (Patient, or Parent/Guardian of Patient) Release of Medical Records: I give my permission for Dr. Rusher and Dr. Pratt to request medical information for other medical facilities that may help the doctor to accurately assess and treat my current condition Signature (Patient, or Parent/Guardian of Patient)

7 Insurance Verification and Financial Policy At Amherst Family Chiropractic Inc. we are committed to providing you and your family with the best chiropractic care possible. We are a wellness based family Chiropractic practice that encourages ongoing chiropractic care (regardless of insurance coverage) for overall health and well-being. Please understand that if you do carry insurance coverage, that there may be a portion of your Doctor recommended care that is outside the allowed standard of insurance visits and/or deemed not medically necessary by your insurance company. You will be expected to pay for your chiropractic care at the time the service is rendered unless you elect to participate in our Chiropractic Care Plan Agreement that include annual or monthly payments. Details of these plans will be discussed during your Report of Findings appointments. Health Insurance: We accept and participate in many plans. Our office is happy to file insurance for you; however, it is important to know that all insurance companies state this disclaimer: VERIFICATION IS NOT A GURANTEE OF PAYMENT. We verify your insurance coverage as a courtesy; this is not a guarantee of benefits. We recommend you contact your insurance company to verify your chiropractic coverage as well. It is your responsibility to thoroughly understand your insurance benefits. You are ultimately responsible for any co-payments, deductibles, and portion of care that is not covered by your health insurance. We strongly advise you to maintain contact with your insurer in order to confirm coverage and benefits. Following this procedure will help to prevent problems with billing and reimbursement. Please verify the following information and return this form to Amherst Family Chiropractic Inc. at your next visit. We will also need a copy of your insurance card for our records. INSURANCE COMPANY ID# Group/Plan# Insurance phone # Co-pay Co-Insurance Deductible Required? Yes No I don t know Has It Been Met To? Yes No I don t know Are X-Rays Covered? Yes No I don t know Referral Needed? Yes No I don t know Number Of Medically Necessary Visits Allowed Effective of Insurance Per: Contract Year OR Calendar Year My Plan Year Runs Medicare patients we are NOT a participating provider for Medicare, however, we will bill out to Medicare on your behalf. Medicare does not cover any examinations, X-Rays, or thermal imaging scans. These fees are the responsibility of patient at the time of service. I, have read and understand the above policies. Print Name Patient Signature